Athletes treated for inguinal-related groin pain by endoscopic totally extraperitoneal (TEP) repair:long-term benefits of a prospective cohort

Purpose: Inguinal-related groin pain (IRGP) in athletes is a multifactorial condition, posing a therapeutic challenge. If conservative treatment fails, totally extraperitoneal (TEP) repair is effective in pain relief. Because there are only few long-term follow-up results available, this study was designed to evaluate effectiveness of TEP repair in IRGP-patients years after the initial procedure. Methods: Patients enrolled in the original, prospective cohort study (TEP-ID-study) were subjected to two telephone questionnaires. The TEP-ID-study demonstrated favorable outcomes after TEP repair for IRGP-patients after a median follow-up of 19 months. The questionnaires in the current study assessed different aspects, including, but not limited to pain, recurrence, new groin-related symptoms and physical functioning measured by the Copenhagen Hip and Groin Outcome Score (HAGOS). The primary outcome was pain during exercise on the numeric rating scale (NRS) at very long-term follow-up.Results: Out of 32 male participants in the TEP-ID-study, 28 patients (88%) were available with a median follow-up of 83 months (range: 69–95). Seventy-five percent of athletes were pain free during exercise (p &lt; 0.001). At 83 months follow-up, a median NRS of 0 was observed during exercise (IQR 0–2), which was significantly lower compared to earlier scores (p &lt;0.01). Ten patients (36%) mentioned subjective recurrence of complaints, however, physical functioning improved on all HAGOS subscales (p &lt;0.05).Conclusion:This study demonstrates the safety and effectivity of TEP repair in a prospective cohort of IRGP-athletes, for whom conservative treatment had failed, with a follow-up period of over 80 months.</p

A hinged external fixator for complex elbow dislocations: A multicenter prospective cohort study

Background: Elbow dislocations can be classified as simple or complex. Simple dislocations are characterized by the absence of fractures, while complex dislocations are associated with fractures of the radial head, olecranon, or coronoid process. The majority of patients with these complex dislocations are treated with open reduction and internal fixation (ORIF), or arthroplasty in case of a non-reconstructable radial head fracture. If the elbow joint remains unstable after fracture fixation, a hinged elbow fixator can be applied. The fixator provides stability to the elbow joint, and allows for early mobilization. The latter may be important for preventing stiffness of the joint. The aim of this study is to determine the effect of early mobilization with a hinged external elbow fixator on clinical outcome in patients with complex elbow dislocations with residual instability following fracture fixation. Methods/Design. The design of the study will be a multicenter prospective cohort study of 30 patients who have sustained a complex elbow dislocation and are treated with a hinged elbow fixator following fracture fixation because of residual instability. Early active motion exercises within the limits of pain will be started immediately after surgery under supervision of a physical therapist. Outcome will be evaluated at regular intervals over the subsequent 12 months. The primary outcome is the Quick Disabilities of the Arm, Shoulder, and Hand score. The secondary outcome measures are the Mayo Elbow Performance Index, Oxford Elbow Score, pain level at both sides, range of motion of the elbow joint at both sides, radiographic healing of the fractures and formation of periarticular ossifications, rate of secondary interventions and complications, and health-related quality of life (Short-Form 36). Discussion. The outcome of this study will yield quantitative data on the functional outcome in patients with a complex elbow dislocation and who are treated with ORIF and additional stabilization with a hinged elbow fixator. Trial Registration. The trial is registered at the Netherlands Trial Register (NTR1996)

Functional treatment versus plaster for simple elbow dislocations (FuncSiE): a randomized trial

Background. Elbow dislocations can be classified as simple or complex. Simple dislocations are characterized by the absence of fractures, while complex dislocations are associated with fractures. After reduction of a simple dislocation, treatment options include immobilization in a static plaster for different periods of time or so-called functional treatment. Functional treatment is characterized by early active motion within the limits of pain with or without the use of a sling or hinged brace. Theoretically, functional treatment should prevent stiffness without introducing increased joint instability. The primary aim of this randomized controlled trial is to compare early functional treatment versus plaster immobilization following simple dislocations of the elbow. Methods/Design. The design of the study will be a multicenter randomized controlled trial of 100 patients who have sustained a simple elbow dislocation. After reduction of the dislocation, patients are randomized between a pressure bandage for 5-7 days and early functional treatment or a plaster in 90 degrees flexion, neutral position for pro-supination for a period of three weeks. In the functional group, treatment is started with early active motion within the limits of pain. Function, pain, and radiographic recovery will be evaluated at regular intervals over the subsequent 12 months. The primary outcome measure is the Quick Disabilities of the Arm, Shoulder, and Hand score. The secondary outcome measures are the Mayo Elbow Performance Index, Oxford elbow score, pain level at both sides, range of motion of the elbow joint at both sides, rate of secondary interventions and complication rates in both groups (secondary dislocation, instability, relaxation), health-related quality of life (Short-Form 36 and EuroQol-5D), radiographic appearance of the elbow joint (degenerative changes and heterotopic ossifications), costs, and cost-effectiveness. Discussion. The successful completion of this trial will provide evidence on the effectiveness of a functional treatment for the management of simple elbow dislocations. Trial Registration. The trial is registered at the Netherlands Trial Register (NTR2025)

Feasibility of a smartphone application for inguinal hernia care:a prospective pilot study

The Inguinal Hernia Application (IHAPP) is designed to overcome current limitations of regular follow-up after inguinal hernia surgery. It has two goals: Minimizing unnecessary healthcare consumption by supplying patient information and facilitating registration of patient-reported outcome measures (PROMs) by offering simple questionnaires. In this study we evaluated the usability and validity of the app. Patients (≥18 years) scheduled for elective hernia repair were assessed for eligibility. Feasibility of the app was evaluated by measuring patient satisfaction about utilization. Validity (internal consistency and convergent validity) was tested by comparing answers in the app to the scores of the standardized EuraHS-Quality of Life instrument. Furthermore, test-retest reliability was analyzed correlating scores obtained at 6 weeks to outcomes after 44 days (6 weeks and 2 days). During a 3-month period, a total of 100 patients were included. Median age was 56 years and 98% were male. Most respondents (68%) valued the application as a supplementary tool to their treatment. The pre-operative information was reported as useful by 77% and the app was regarded user-friendly by 71%. Patient adherence was mediocre, 47% completed all questionnaires during follow-up. Reliability of the app was considered excellent (α &gt; 0.90) and convergent validity was significant (p = 0.01). The same applies to test-retest reliability (p = 0.01). Our results demonstrate the IHAPP is a useful tool for reliable data registration and serves as patient information platform. However, further improvements are necessary to increase patient compliance in recording PROMs.</p

Value and patient appreciation of follow-up after endoscopic totally extraperitoneal (TEP) inguinal hernia repair

Purpose: There is some consensus on inguinal hernia surgery follow-up in research settings. However, consensus on regular follow-up is lacking. Therefore, patients and surgeons are unnecessarily burdened and not cost-efficient. Moreover, the purpose of follow-up is barely questioned. This study aims to evaluate follow-up after inguinal hernia repair and determine patient satisfaction. Methods: This prospective cohort study was executed in a high-volume specialized hernia clinic. All totally extraperitoneal (TEP) repair patients between July and October 2016 were included. Telephone follow-up was performed at 1 day, 6 weeks and 1 year postoperatively. One year postoperatively it was assessed whether patients visited other healthcare organizations, had remaining inguinal complaints, a Post-INguinal-repair-Questionnaire by telephone (PINQ-PHONE) was executed, and appreciation with follow-up was determined. Results: Respectively, 6 weeks and 1 year postoperatively, 138 (79.3%) and 130 (74.7%) of 174 included patients were reached. One year postoperatively 15 patients (11.5%) had remaining inguinal complaints, of which only four patients (3.1%) had not already reported their symptoms. Nineteen patients (14.6%) presented with self-reported complaints between 6 weeks and 1 year, and no patients went to other hospitals. Respectively, 107 (82.3%), 61 (46.9%) and 117 (90.0%) patients considered follow-up useful at 6 weeks, 1 year and in general. One hundred nineteen patients (91.5%) preferred telephone follow-up to outpatient clinic appointments. Conclusion: TEP patients value a telephone follow-up time-point, however, long-term follow-up is not considered useful. Patients report postoperative complaints themselves, therefore performing follow-up serves no clinical purpose. The purpose of follow-up is patient satisfaction and registration for quality objectives

Differentiation in an inclusive trauma system : Allocation of lower extremity fractures

Background: Implementation of an inclusive trauma system leads to reduced mortality rates, specifically in polytrauma patients. Field triage is essential in this mortality reduction. Triage systems are developed to identify patients with life-threatening injuries, and trauma mechanisms are important for triaging. Although complex extremity fractures are mostly non-lethal, these injuries are frequently the result of a high-energy trauma mechanism. The aim of this study is to compare injury and patient characteristics, as well as resource demands, of lower extremity fractures between a level (L)1 and level (L)2 trauma centre in a mature inclusive trauma system. Methods: This is a retrospective cohort study. Patients with below-the-knee joint fractures diagnosed in a L1 or L2 trauma centre between July 2013 and June 2015 were included. Main outcome parameters were patient demographics, trauma mechanism, fracture pattern, and resource demands. Results: One thousand two hundred sixty-seven patients with 1517 lower extremity fractures were included. Most patients were treated in the L2 centre (L1=417; L2=859). Complex fractures were more frequently triaged to the L1 centre. Patients in the L1 centre had more concomitant injuries to other body regions and ipsi- or contralateral lower extremity. Patients in the L1 centre were more resource demanding: more surgeries (>1 surgery; 24.9% L1 vs 1.4% L2), higher immediate admission rates (70.1% L1 vs 37.6% L2), and longer length of stay (mean 13.4 days L1 vs 3.1 days L2). Conclusion: The majority of patients were treated in the L2 trauma centre, whereas complex lower extremity injuries were mostly treated in the L1 centre, which placed higher demand on resources and labour per patient. This change in allocation is the next step in centralization of low-volume high complex care and high-volume low complex care

Differentiation in an inclusive trauma system : Allocation of lower extremity fractures

Background: Implementation of an inclusive trauma system leads to reduced mortality rates, specifically in polytrauma patients. Field triage is essential in this mortality reduction. Triage systems are developed to identify patients with life-threatening injuries, and trauma mechanisms are important for triaging. Although complex extremity fractures are mostly non-lethal, these injuries are frequently the result of a high-energy trauma mechanism. The aim of this study is to compare injury and patient characteristics, as well as resource demands, of lower extremity fractures between a level (L)1 and level (L)2 trauma centre in a mature inclusive trauma system. Methods: This is a retrospective cohort study. Patients with below-the-knee joint fractures diagnosed in a L1 or L2 trauma centre between July 2013 and June 2015 were included. Main outcome parameters were patient demographics, trauma mechanism, fracture pattern, and resource demands. Results: One thousand two hundred sixty-seven patients with 1517 lower extremity fractures were included. Most patients were treated in the L2 centre (L1=417; L2=859). Complex fractures were more frequently triaged to the L1 centre. Patients in the L1 centre had more concomitant injuries to other body regions and ipsi- or contralateral lower extremity. Patients in the L1 centre were more resource demanding: more surgeries (>1 surgery; 24.9% L1 vs 1.4% L2), higher immediate admission rates (70.1% L1 vs 37.6% L2), and longer length of stay (mean 13.4 days L1 vs 3.1 days L2). Conclusion: The majority of patients were treated in the L2 trauma centre, whereas complex lower extremity injuries were mostly treated in the L1 centre, which placed higher demand on resources and labour per patient. This change in allocation is the next step in centralization of low-volume high complex care and high-volume low complex care